Fill and Sign the Emergency Denied Form

SAMPLE PHYSICIAN’S AFFIDAVIT (Emergency -Denied ) Patient Name: ____ Jane Doe ______________________________ TO BE COMPLETED WHEN REQUESTING AN EMERGENCY GUARDIANSHIP Nature of the emergency, such as medical, abuse, neglect, exploitation, etc.: __abuse _______________________________________________________________________ _____________________________________________________________________________ _______________________________________________ ______________________________ If this is a medical emergency provide the diagnosis: __ developmental delay___________________________________________________________ ____possible caregiver abuse______________________________________________________ _____________________________________________________________________________ ____________________________________________________________________ _________ Describe the testing or treatment related to the diagnosis that is urgently needed and why it is urge ntly needed within the next 72 hours: ___ due to developmental delay, patient needs an immediate caregiver______ ___________________________________________________________________________ ____________________________________________________________________ _______ ________________________________________________________________________ ___ _____________________________ ___________________________ _______ Date Physician’s Signature ____________________________ ______ Printed Name SWORN TO AND SUBSCRIBED before me this _______day of ___________ 20__. ____________________________ Notary Public SAMPLE PHYSICIAN’S AFFIDAVIT (Emergency -Granted ) Patient Name: ____ David Jones ______________________________ TO BE COMPLETED WHEN REQUESTING AN EMERGENCY GUARDIANSHIP Nature of the emergency, such as medical, abuse, neglect, exploitation, etc.: __medical emergency___________________________________________________________ _____________________________________________________________________________ _______ ______________________________________________________________________ ________________________________________ ______________________________ If this is a medical emergency provide the diagnosis: __ patient has severe dementia with combative behavior and is refusing treatment for gangrene on hands and feet; immediate treatment is necessary to prevent the spread and to ward against the need for amputation; untreated gangrene can spread quickly and be d eadly_____ _____________________________________________________________________________ ____________________________________________________________________ _________ Describe the testing or treatment related to the diagnosis that is urgently needed and why it is urgently needed within the next 72 hours: ___ doctors need access to the patient to best assess how to treat the gangrene expeditiously, including, if necessar y, through emergency surgery, amputation, oxygen therapy, and/or injection of antibiotics___________________________________________________ ___________________________________________________________________________ ________________________________________ ___________________________________ ________________________________________________________________________ ___ _____________________________ ___________________________ _______ Date Physician’s Signature ____________________________ ______ Printed Name SWORN TO AND SUBSCRIBED before me this _______day of ___________ 20__. ____________________________ Notary Public